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Spontaneous pneumothorax
In spontaneous pneumothorax, treatment is decided by symptoms and not only by size: primary in a young person without lung disease — conservative, needle aspiration or a small drain; secondary in a patient with lung disease — admission and a drain in most cases; and tension pneumothorax — immediate needle decompression.
Why it matters in the exam
The typical question presents a tall, thin young male smoker with sudden chest pain and breathlessness, or a COPD patient with a sudden worsening of breathlessness. Primary pneumothorax is separated from secondary, in which the danger is much greater. According to current guidance, a young person with minimal symptoms can be managed conservatively even when the pneumothorax is large.
The numbers are also tested: a pneumothorax is large when the distance between the lung and the chest wall at the level of the hilum is 2 cm or more. In secondary pneumothorax: below 1 cm — oxygen and observation in hospital; 1–2 cm — needle aspiration; above 2 cm or breathlessness — a drain. Needle decompression of tension pneumothorax in adults is done in the fourth or fifth intercostal space in the anterior-mid axillary line.
Recurrence prevention is also asked: surgery (VATS with pleurodesis) is recommended after a second episode, after a first episode in high-risk occupations (pilots, divers), with a persistent air leak or with bilateral pneumothorax. After a pneumothorax, flying is avoided until a week after full radiological resolution, and diving is permanently forbidden unless preventive surgery has been done. High-concentration oxygen speeds absorption of the air, but carbon dioxide must be monitored in COPD patients.
Key points
- Primary — young without lung disease; secondary — in lung disease and more dangerous.
- Primary with few symptoms — conservative; with symptoms — aspiration or a small drain.
- Secondary — admission, and usually a drain.
- Tension pneumothorax — needle at once in the fourth or fifth space.
- Preventive surgery after a second episode or with occupational risk.
Summary table
| Situation | Finding | Treatment | Note |
|---|---|---|---|
| Primary, minimal symptoms | Young, no lung disease | Conservative, outpatient follow-up | Even when large |
| Primary with symptoms | Significant breathlessness or pain | Needle aspiration or a small drain | If it fails — a drain |
| Secondary | COPD or other lung disease | Admission; above 2 cm or breathless — drain; 1–2 cm — aspiration | Greater danger |
| Tension pneumothorax | Hypotension, full neck veins, absent breath sounds | Immediate needle decompression, then a drain | Clinical diagnosis, no X-ray |
| Recurrence or occupational risk | Second episode, pilot, diver, persistent leak | VATS and pleurodesis | Prevention |
A free exam question
אישה בת 45, התקבלה למלר"ד לאחר תאונת דרכים במנגנון התנגשות חזיתית במהירות גבוהה, .בהיותה חגורה. יציבה המודינמית איזו ?מהתמונות הקליניות הבאות מהווה אינדיקציה להעברה מוקדמת לחדר ניתוח (the question as examined, in Hebrew)
- א. הוכנס נקז חזה עקב סמני חזה דם Hemothorax ), עם יציאה של כ- 1000 מ"ל דם. (שוקלת 65 .)ק"ג
- ב. ב- CT ( רואים חזה אוויר Pneumothorax ) קטן ומעט אוויר חופשי בבטן. ( Pneumoperitoneum .) ללא מקור ברור
- ג. ב- CT רואים Pseudoaneurysm of the left common carotid artery . בדיקה. נוירולוגית תקינה, יש סימן חגורה באזור הצוואר
- ד. ב- CT רואים Grade V renal injury
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Sources
- British Thoracic Society Guideline for pleural disease, 2023 — Spontaneous pneumothorax
- ERS/EACTS/ESTS statement on the management of spontaneous pneumothorax, 2015 — Treatment and recurrence prevention
- ATLS Advanced Trauma Life Support, Student Course Manual (American College of Surgeons), 10th edition (2018) — Needle decompression site
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.